RC 

74- 
C7 


CHAMP roX:    BLOOD   PTOSIS. 


them.  The  former  viewpoint,  therefore,  is  inde- 
fensible and  false.  And  yet,  this,  practically,  seems 
to  be  the  manner  in  which  some  Freudians  con- 
template the  situation.  Their  explanation  of  the 
exaggerated  ego  in  paranoia  (as  being  based  on 
sexuality)  tells  the  tale. 

Do  love  and  life  mean  only  sexual  love  and 
sexual  life?  Is  all  unconscious  thinking  sexual? 
Are  all  unconscious  processes  sexual  in  nature  ?  Is 
all  intrapsychic  struggles  sexual?  Is  sexuality  the 
underlying  impulse  in  physiological  tropisms,  in 
physicochemical  reactions,  in  all  attraction  and  re- 
pulsion, physical  or  psychic,  in  the  organic  or  in- 
organic world? 

The  I'reiKlians  have  assumed  a  purely  psycholo- 
gic viewpoint.  They  have  confined  their  psychology 
to  sexology. 

The  biological  viewpoint  is  the  basic  method  of 
approach  to  a  study  of  the  mind  of  man.  Biological 
relations  cannot  be  explained  from  a  purely  psy- 
chological conception  of  the  universe.  And  psycho- 
logical relations  can  l)e  explained  not  from  the  psy- 
chological aspect  alone,  nor  even  from  the  bio- 
logical standpoint  alone,  but  only  on  a  psychologi- 
cal basis. 

Man  can  be  understood  only  if  we  agree  that 
he  is  composed  of  a  bundle  of  instinctive  tenden- 
cies. Man  does  not  breathe  and  eat  and  digest 
and  sleep  and  dream  and  exercise  his  physical  and 
psychical  faculties  because  he  is  constantly  demand- 
ing and  seeking  gratification  of  his  complex  sexual 
mipulse,  no  matter  how  broadly  this  term  be  con- 
strued, but  because  he  instinctively,  innately,  and 
frequently  blindly,  must  strive  and  tend  toward  self 
expression  all  his  livelong  life. 

In  conclusion  I  wish  to  state  that  these  questions 
have  not  been  propounded  with  a  feeling  of  fixed 
antagonism  and  blind  hostility,  but  with  a  sincere 
desire  to  know  "the  truth,  the  whole  truth  and 
nothing  but  the  truth." 

If  certain  Freudian  teachings  regarding  the  role 
of  sexuality  are  not  according  to  facts  as  we  know 
them  to  be,  then  they  should  be  quickly  and  surelv 
bombarded  and  shattered.  And  the  sooner  this  is 
Jone.  the  better  will  it  be  for  science  and  for  psy- 
chotherapy. 

1 51 7  South  Kedzie  Avenue. 


BLOOD  PTOSIS. 

A  Test  of  Vasomotor  Efficiency* 

By  C.  Ward  Crampton    M.  D., 

New   York, 

Director  of  Physical  Training,  Department  of  Education. 

\\'e  have  few  if  any  accurate  scientific  tests  of 
health.  On  this  account  school  hygiene  shares 
\yith  other  branches  of  medicine  a  difficulty  in. 
quickly  and  certainly  testing  the  failure  or  «:uccess 
of  Its  methods.  We  labor  to  improve  the  health  of 
school  children  and  to  increase  their  prospects  of 
hfe  by  physical  training,  athletics,  instruction  in  hv- 
lene  school  lunches,  open  air  classes,  changes  in 
ventilation  and  the  like  and  invariably  experience 
difficulty  m  clearly  and  honestly  stating  what  gain 


tlLUUU    PlOiilS.       ::.■.;;'.  ..     ..,      [New  VoBK 

'c.'  i''[  ;     '/  '    ]  '<■'   Medical  Journal. 

has  been  madle  V-.oiir  jvvpck;  ."JtJ-iS  .true  that  such 
;  records  of  rates  brittc!rtiise 'ind  (Ife'creise  of  hemo- 
globin have  their  value,  and  certain  strength  and 
endurance  tests  have  some  merit,  but  they  are  all 
subject  to  error,  and  are  incomplete  or  difficult  to 
control. 

During  the  course  of  an  exhaustive  study  on  blood 
iitessure^  I  presented  a  preliminary  report  on  a  test 
i     which  fulfils  the  latter  requirements.* 

It  is  a  statement  of  the  efficiency  of  the  vasomotor 
system  m  responding  to  the  necessity  of  raising  the 
blood  pressure  upon  rising  from  the  recumbent  to 
the  standing  position. 

In  the  perfectly  normal  vigorous  male  the  blood 
pressure  will  rise  from  eight  to  ten  millimetres  of 
mercury  upon  assuming  the  standing  position.  In 
one  damaged  by  disease,  overwork  or  unhygienic 
living  or  weakened  by  inactivity,  the  blood  pressure 
will  fail  to  rise  and  may  fall  as  much  as  ten  milli- 
rnetres  of  mercury.  The  heart  rate  acts  in  exactly 
the  opposite  fashion,  rising  in  proportion  to  weak- 
ness as  much  as  forty-five  beats  a  minute,  but  only 
in  exceptional  cases  falling.  These  two  adjust- 
ments are  interdependent,  one  often  masking  the 
failure  of  the  other,  and  both  must  be  considered 
and  balanced.  If  blood  pressure  were  alone  con- 
sidered many  cases  showing  a  high  heart  rate  would 
be  given  a  good  rating  when  it  should  be  poor,  and 
vice  versa.  This  test  has  been  put  into  rcgular 
routine  practice  by  R.  Tait  Mackenzie,  M.  D.,  oi  the 
Lmversity  ot  Pennsylvania:  George  H,  Mevlan, 
M.D.,  of  Columbia  University;  Doctor  Raycroft 
of  Princeton ;  Doctor  Storey,  of  the  College  of  the 
City  of  New  York ;  Doctor  Marks,  of  Pittsburgh  • 
Doctor  McCurdy,  of  Springfield,  and  others  in  ex- 
amination of  athletes  for  "permission  to  compete" 
and  for  other  purposes.  It  is  based  upon  the  fol- 
lowing facts: 

If  the  blood  were  contained  in  ilaccid  tubes 
without  support  it  would,  upon  standing,  drop  to 
the  lowest  possible  point  and  remain  there.  There 
would  be  none  to  reach  the  heart  and  none  would 
be  pumped  to  the  head.  A  complete  blood  ptosis 
wou.d  occur  and  death  would  result  at  once.  This 
does  not  occur  because  there  is  some  mechanical 
support  and  the  blood  vessels  are  not  flaccid  but 
helQ  to  a  narrow  lumen  by  circular  muscles,  in  turn 
controlled  by  the  sympathetic  nervous  system.  The 
most  capacious  system  of  blood  vessels  in  the  body 
are  the  splanchnic  veins;  these  can  hold  all  the 
bk)od  volume  if  released  from  the  vasoconstrictor 
ettorts  of  the  nervous  system. 

In  the  perfectly  normal  there  occurs  upon  risin  - 
trom  the  recumbent  position  a  vasoconstriction  ef- 
;  tort  which   squeezes  these  veins  and  raises  blood 
pressure  which  more  than  overcomes  the  added  hv- 
**drostatic  load.    In  the  subnormal  this  vasoconstric- 
tion eflFort   is  relatively  weak  and   inefl^ective  and 
does  not  raise  the  blood  pressure  in  the  upper  body 
but   allows   It  to    fall    under   hydrostatia  pressure. 
1  here  is  a  blood  ptosis  due  to  the  relative  failure 
of  vasomotor  tone.     This  may  be  mild,  merely  a 
tailure  to  raise  the  pressure  or  a  fall  of  the  systolic 
pressure  five  or  ten  millimetres,  in  which  case  we 

tio'^'^^S'^  ^B/*!?V^:ff*"^"'rGold  Medal  TheVis7st.  Louis  Expo^- 
Procedure:  P' "^"re    m    Its   Relations    to   Physical   TravninK 

loTl^goi"'  Hrf>"-a,io«   Re,u„.   i9r>s.,9„6;  Medical  News.   September  ^ 


7GZG9Z 


November  8,  1913.I 


CRAMPTON:    BLOOD   PTOSIS. 


...,^  .omial.  It  may  be 
„ ^ ,  Jowing  the  systolic  pres- 
sure "to  drop  to  forty  or  fifty,  at  which  point  the 
patient  faints  from  cerebral  anemia.  This  is  the 
familiar  picture  seen  when  a  convalescent  patient 
with  vasotone  damaged  rises  prematurely  from  a 
sick  bed.  and,  robbing  the  splanchnic  veins  of  me- 
chanical support  by  emptying  the  bladder,  falls  to 
the  floor. 

The  most  severe  grade  of  vasotone  paralysis  oc- 
curs as  a  terminal  phenomenon  in  poisoning  from 
disease  in  which  case  the  patient  literally  bleeds  into 
his  abdominal  veins  and  dies.  Vasotone  is  then  a 
function  essential  to  life;  a  delicate  measurement  of 
its  efficiency  such  as  is  indicated  in  the  foregoing 
is  worthy  of  consideration  as  an  important  indica- 
tion of  the  condition  and  vitality  of  the  whole  body, 
which  depends  upon  vasotone  for  its  proper  func- 
tioning. 

It  would  then  seem  to  be  necessary  merely  to  ob- 
serve the  amount  of  rise  or  fall  of  the  systolic  pres- 
sure at  a  convenient  point  in  the  upper  body  to  de- 
termine the  efficiency  of  the  vasomotor  system  and 
its  reverse,  the  amount  of  blood  ptosis. 
''Another  fact  presents  itself  in  the  increase  in 
-^  heart  rate  which  accompanies  vasotone  failure. 
I  Hill  states  that  the  heart,  as  it  were,  comes  to  the 
rescue  of  the  falling  pressure  by  beating  faster  in  a 
successful  endeavor  to  reestablish  it,  its  rate  increas- 
ing in  proportion  to  the  necessity.  In  this  case  we 
would  discover  weakened  vasotone  by  either  in- 
creased heart  rate,  or  fall  in  blood  pressure,  or  both, 
but  only  by  taking  both  into  consideration,  we  may 
arrive  at  a  correct  estimation  of  the  weakness.  .An- 
other explanation  maintains  that  the  increased  heart 
rate  does  not  raise  the  pressure  but  merely  reveals 
it,  for  the  heart  furnished  with  a  lessened  charge  of 
blood  is  able  to  send  it  into  the  arteries  more 
quickly. 

From  my  own  observation  it  is  clear  that  a  single 
patient  will  show  in  successive  readings  a  variation 
of  blood  pressure  and  heart  rate  which  compensate 
each  other,  while  the  consideration  of  both  will  re- 
veal no  change  in  vasotone  efficiency. 

The  balancing  of  these  two  is  a  matter  of  some 
importance.  The  us>ial  range  of  the  systolic  pres- 
sure is  from  -}-  lo  to  — lo  of  the  heart  rate  increase 
from  o  to  44,  as  observed  from  records  of  a  large 
number  of  cases.  Upon  a  statistical  balancing  of 
these  two  series  of  frequencies,  and  assigning  equal 
percentages  to  equal  ranges,  the  following  scale  is 
constructed. 

,        PERCENTAGE  SCALE. 
^  Vasomotor  Tone. 

Blood  Pressure. 

Heart  rate  / Increase x  , Decrease s 

increase.  -f  10    +8  +6    +4    +3      o      — 2  — 4    — 6    — 8    — 10 

o  to    4 100  95  90  8s  80  75  70  65  60  55  50 

5  to    8 95  90  85  80  75  70  65  60  55  50  45 

9  to  12 90  85  80  75  70  65  60  55  50  45  40 

13  to  16 85  80  75  70  65  60  55  50  45  40  35 

17  to  20 80  75  70  65  60  55  50  45  40  35  30 

21  to  24 75  70  65  60  55  50  45  40  35  30  25 

25  to  28 70  65  60  55  50  45  40  35  30  25  20 

291032 65  60  55  50  45  40  35  30  25  20  15 

33  to  36 60  55  50  45  40  35  30  25  20  15  ID 

37  to  40 55  50  45  40  35  30  25  20  15  10  5 


mits  a  numerical  statement  of  the  function  m  cjues- 
tion.  Its  100  mark  indicates  \  perfectly  efficient 
working  of  the  vasomotor  system  under  test,  the 
zero  is  approximately  the  point  where  the  average 
person  is  unable  to  maintain  the  erect  posture. 

The  technic  of  the  test  is  as  follows : 

The  sphygmomanojneter  is  adjusted  over  the 
brachial  artery  and  the  patient  is  placed  on  a  com- 
fortable couch  with  a  low  pillow.  The  heart  state 
is  counted  by  quarter  minutes  and  a  gradually  de- 
creasing rate  is  usually  observed.  Counting  should 
continue  until  two  successive  quarter  minutes  are 
the  same,  this  is  niuhii^lied  by  four  and  recorded. 
The  systolic  pressure  is  then  taken  preferably  by 
auscultation.  The  patient  stands,  the  heart  rate  is 
counted  as  before  until  it  reaches  the  "standing 
normal,"  when  it  is  recorded,  and  the  blood  pressure 
is  then  taken.  The  diflferenccs  are  calculated  and 
reference  is  made  to  the  scale. 

For  example — Case  XX  :    L.   \'..  age   seventeen 
years,  asserts  to  be  in  good  condition  at  ii  :20  a.  m. 


Horizontal  

Vertical   

Difference  

Percentage  record  20 

Pnlee  rate. 

68 

104 

-f-36 

niood  press 
100 
94 

This  is  a  very  poor  record  taken  from  an  appar- 
ently normal  strong  young  football  player  of  ex- 
ceptional ability  who  had  previously  given  records 
above  80. 

rr  was  at  a  loss  to  account  for  this,  for  question- 
ing failed  to  bring  out  any  history  of  loss  of  sleep, 
dissipation,  or  illness.  He  looked  quite  as  "fit"  as 
usual.  He  was  absent  next  day,  and  remained 
home  for  a  week  with  a  "cold  and  fever."  It  is 
evident  that  the  test  revealed  a  weakened  vasotone, 
the  beginning  of  actual  illness  before  any  other 
symptom  could  be  noted.  Others  who  .have  used 
this  test  have  noted  similar  cases. 

This  test  has  been  used  to  follow  athletes  through 
a  course  of  training  and  as  the  basis  for  choice  for 
the  entry  of  one  of  several  athletes  of  equal  ability 
in  an  important  race  where  only  one  might  com- 
pete. It  has  been  used  to  guide  the  daily  exercise 
of  athletes  to  guard  against  overwork  and  ap- 
proaching staleness.  It  has  been  foimd  useful  in 
guiding  treatment  of  the  neurasthenic  and  over- 
worked. 

It  has  been  used  in  school  hyg^ene  to  determine 
the  amount  of  physical  cost  of  school  procedures  of 
various  kinds.    The  following  is  a  typical  record. 

Increase  Increase 


inilse 

blood 

Per- 

Ti:rc. 

rati-. 

pressure. 

centage. 

Reinarlts. 

9:43  a. 

111. 

0 

+  10 

100 

Slept  well,  no  exercise. 

10:45  a. 

m. 

0 

-f  4  <i<  ^  j 

After  lesson  in  physics 
standing. 

1 1  :50  a. 

m. 

.  ~8 

-fio 

95 

After  lesson  in  algebra. 

12:24  -I. 

m. 

•   -f  5 

-f6 

85 

After  lesson  in  French. 

1  :io  p. 

m. 

.  +6 

-f-8 

90 

.'\fter  lunch  and  rest. 

2:00  p. 

m. 

.^14 

+8 

80 

.^fter  history  lesson. 

2:35  P- 

m. 

.-fi6 

+4 

70 

.\ftcr  slow  one  mile  run. 

50    45    40    35    30    25    20    15     10      5      o 

■In   case   of   increase   in   pressure   higher   than    +i<>  add    s 
to  the   -r'o  column   for  each  2  millimetres  in  excess  of   10. 


This  shows  that  one  period  of  work  in  the 
physics  laboratory  (which  required  continued 
standing)  was  more  expensive  than  a  slow  mile 
run.  it  also  showed  that  this  was  partially  re- 
gained in  the  next  period,  lost  again  during  the 


I'LLIJ:).    .tXaiXA    riLCTORIS. 


French  period,  and  partially  regained  by  rest  at 
the  lunch  period.  This  record  also  shows  the  im- 
portance of  considering  both  heart  rate  and  blood 
pressure. 

This  test  open's  a  wide  field  of  investigation 
hitherto  unworked.  The  effect  of  various  modes 
of  ventilation,  of  feeding,  exercise,  and  other  hy- 
gienic procedure  may  be  tested  and  recorded  in 
terms  which  may  be  statistically  stated  and  easily 
compared  with  a  control  series  of  records. 

It  has  been  used  to  test  the  amount  of  relaxation 
of  vasotonc  resulting  from  various  forms  of  phy- 
sical exercise,  and  shows  clearly  that  exercise  is 
expensive  of  nervous  energy  and  should  be  fol- 
lowed by  rest  and  recuperation. 

This  test  will  not  reveal  more  than  it  assumes  to 
test,  i.  e.,  the  efficiency  of  the  vasomotor  system. 
It  will  not  show  the  presence  of  a  mitral  lesion  any 
more  than  it  will  a  decayed  tooth.  Nor  will  it  test 
other  factors  of  efficiency  such  as  will  power,  in- 
hibition, or  skill ;  it  does  provide  a  means  of  making 
a  definite  record  of  an  all  important  bodily  function. 
Those  who  work  to  mould  schoolroom  and  other 
living  conditions  for  the  purpose  of  improving 
health  and  efficiency  may  be  able  by  this  means  to 
measure  the  benefit  resulting  from  their  labors. 

431  Riverside  Drive. 


THE    REFLEX    OR    PROTECTI\E    PHE- 
NOMENA OF  ANGINA  PECTORIS. 

By  W.  J.  Pulley.  M.  D.. 
Ig^Bg^     New  York. 

It  is  not  my  purpose  to-night  to  discuss  angina 
pectoris  in  detail,  but  to  confine  my  remarks  to  a 
discussion  of  what  James  Mackenzie  calls  the  re- 
flex or  protective  phenomena  of  it.  I  have  chosen 
this  part  of  the  clinical  picture  of  angina  pectoris 
to  talk  about  because  it  seems  to  me  to  be  more 
or  less  definite  and  explainable,  while  the  causative 
pathology,  symptomatology,  etc.,  are  more  or  less 
indefinite  and  variable,  and  furthermore,  there  are 
two  additional  points  about  it  which  I  consider  im- 
portant and  which  I  have  not  seen  sufficiently  em- 
phasized in  the  literature  of  the  subject.  For  fear 
of  becoming  too  didactic  I  will  state  simply  that  the 
heart,  according  to  Engelmann  and  his  followers, 
has  five  functions  more  or  less  well  defined,  viz. : 

1.  Stimulus  production  or  rhythmicity.  The  heart 
takes  a  certain  length  of  time  to  produce  enough 
stimulus  to  cause  a  normal  contraction,  and  the 
length  is  the  same  between  all  of  the  beats. 

2.  Excitability,  or  the  po\^e^  of  being  able  to  re- 
ceive stimulus. 

3.  Conductivity,  or  the  power  of  conveying 
stimulus  from  fibre  to  fibre. 

4.  Contractility,  or  the.  power  of  contracting 
when  stimulated. 

5.  Tonicity,  or  the  power  to  retain  a  certain 
amount  of  contractility  between  the  active  move- 
ments. 

There  are  some  who  deny  that  these  heart  func- 
tions can  be  isolated  and  definitely  demonstrated, 
and  the  principle  reasons  they  point  out  as  against 
it  is  that,  taking  the  assumption  as  a  basis,  many 
of  the  cardiac  irregularities  cannot  be  explained. 


However,  since  Mackenzie  has  perfected  the  I'oly- 
graph  and  Eithoven  the  clcctrocardiagraph,  a  de- 
rangement of  any  of  the  known  functions  of  the 
heart  can  be  demonstrated.  Ivxactness  of  results 
accjuired  from  the  use  of  these  instruments  was 
made  possible  by  animal  experimentation. 

James  Mackenzie  says:  "I  have  a  great  many 
tracings  from  patients  who  have  suflFered  fn  ni 
angina  pectoris — during  the  attacks  and  when  free 
from  pain— and  an  analysis  of  these  tracings 
enables  me  to  say  with  cemfidencc  that  angina  pec 
toris  can  occur  when  the  e.Ncital)ility.  the  conduc- 
tivity, and  the  power  to  produce  rhythmical  stimuli 
are  unimp.iircd.  There  only  remains  now  the  func- 
ti()n  of  tonicity  and  contractility.  The  evidence  of 
failure  of  the  function  of  tonicity  is  mainly  shown 
in  dilatation  of  the  heart,  and  "typical  attacks  of 
angina  pectoris  frequently  occur  in  hearts  perfectly 
normal  in  size.  Therefore  angina  pectoris  mav 
occur  without  any  evidence  of  the  impairment  of 
the  function  of  tonicity.  Seeing  that  angina  pec- 
toris can  occur  in  patients  when  four  out  of  five 
functions  of  the  heart  muscle  are  demonstrably  in- 
tact, we  are  led  to  inquire  whether  angina  pectoris 
may  not  be  due  to  an  impairment  of  the  remaining 
function,  that  is  contractility." 

Carrying  out  this  line  of  reasoning,  he  states  that 
itis  his  opinion  that  angina  pectoris  is  an  evidence 
of  an  exhaustion  of  the  function  of  contractility. 
To  my  mind  this  looks  to  a  great  extent  reasonable, 
at  least  it  gives  us  a  very  attractive  way  of  explain- 
ing some  of  the  symptoms  of  angina  pectoris  satis- 
factorily, especially  the  reflex  ones,  only  two  of 
which  we  will  deal  with  in  this  paper.  Pain  and 
reflex  muscular  contraction  are  the  symptoms  here 
referred  to,  both  of  which  are  reflexly  produced 
and  protective  in  their  action.  That  these  reflex 
phenomena  are  due  solely  to  an  impairment  of  the 
contractile  function  of  the  heart  does  not,  I  believe, 
explain  the  entire  situation,  for  there  must  of 
necessity  be  present  with  it  a  great  distress  of  the 
function  of  tonicity,  if  not  a  beginning  impairment. 
Mackenzie  uses  the  words  exhausted  and  impaired 
here,  evidently  leading  one  to  infer  that  the  power 
of  the  heart  muscle  to  contract  is  partly,  at  least, 
lost.  I  think  the  real  condition  of  affairs  would  be 
more  correctly  stated  by  saying  that  the  heart 
muscle  is  embarrassed  and  fatigued  by  contracting^ 
against  an  abnormal  obstruction  modified  by  certain 
conditions,  for  the  heart  muscle  must  be  to  a  great 
degree  intact  in  order  to  send  out  the  stimuli  s  » 
constantly  and  strongly  as  to  produce  irritation  in 
the  reflex  nerve  centres. 

In  a  heart  muscle  in  which  the  function  of 
tonicity  is  impaired  these  symptoms  of  angina  pec- 
toris do  not  usually  occur,  even  if  the  function  of 
contractility  is  embarrassed.  In  order  then  to  have 
these  reflex  phenomena  occur,  clearly,  there  nnist 
be  an  overstimulation  of  the  function  of  tonicity 
as  well  as  of  the  function  of  contractility.  As  a 
proof  of  this  I  will  cite  you  a  case  taken  from  my 
files,  in  which  repeated  attacks  of  angina  pectoris 
occurred,  until  the  function  of  tonicity  became  im- 
paired, after  which  they  became  greatly  modified 
and  finally  ceased  altogether.  The  impairment  of 
the  function  of  tonicity  was  easily  recognized  by 
the  development  of  a  systolic  murmur  at  the  apex, 
evidently  a  relative  mitra't  insufficiency  and  a  slight 


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